Assess Build Create Deliver Evaluate

Robert Aunger

Val Curtis

Sian White

Ben Tidwell

• introduction

Self-help

Public health Marketing

Product design

City

planning

Behaviour

change is

hard?

Psychological mismatch

Highly rewarding behaviours

have become unhealthy

Healthy behaviours are not

rewarding

Trade-offs

(Temporal imbalance)

Behaviours Short Term (Rewards) Long Term (Benefits)

Unhealthy ++ --

Healthy -- ++

…but executive function is weak/limited

Behaviour change is only necessary when

‘natural’ learning doesn’t occur

Claim

Reinforcement Learning Video

Reinforcement learning

Stimulus Implementation Sensation/

Perception

What’s

that

smell?

It might

be food!

Consumption

But it was

really

tasty! Just as I

thought:

that filled

me up.

Expected vs Actual

Reward

Get

exposure Grab

attention

Disrupt

setting

Modify

value Get

selected

Alter

rewards

[Behaviour] [Body] [Environment] [Intervention] [Brain]

Performance Revaluation Surprise

Behaviour Setting

Assess & Build

Create

Deliver

Intervention Environment

BCD Program Process Model

Behaviour

Evaluate

State-of-

the-World

Performance Revaluation Surprise

[Outcomes] [Outputs] [Implementation] [Inputs] [Impact]

Brain

Body

Theory of Planned Behaviour

Behaviour Setting

Intervention Environment State-of-

the-World

Performance Revaluation Surprise

Behaviour Setting

Intervention Environment

Behavioural economic tactics

Behaviour State-of-

the-World

Brain

Body

‘First move’

reciprocity

Financial

incentives

Restructuring

physical

setting

Framing, Loss

aversion,

Temporal

discounting,

Planning

fallacy,

Commitment

Status

quo bias

‘Hot-cold’

empathy gap

Emotional

consequences

(e.g., Thaler and Sunstein, 2008;

Ariely, 2009, etc.)

• the BC challenge

Behaviour Setting

Intervention

BCD BC Challenge Process Model

State-of-

the-World

Performance Revaluation Surprise

Alter resources

Modify value Disrupt settings

Get selected

Get exposure

Grab attention

Assess & Build

Create

Deliver Evaluate

Behaviour Environment Brain/Body

[Outcomes] [Outputs] [Implementation] [Inputs] [Impact]

Create Surprise

GET EXPOSURE GRAB ATTENTION

Cause Revaluation

ALTER REWARDS MODIFY VALUE

human

mammal

primate

reptile Create

Affiliate Nurture Attract Love

Hoard

Origins

Fear Disgust Hunger Comfort

Lust Curiosity

Play

body (drives)

brain (interests)

world (emotions)

Human Motives

Justice

Status

(Aunger and Curtis,

2013)

Modifying Value Video

Facilitate Performance

DISRUPT SETTING GET SELECTED

Prop

Infrastructure Competencies

Role/

Script/

Norms

Routine

Stage

Food Hygiene Trial:

Multiple BC in Nepal

1. Cleanliness of

child food serving

utensils using

ash/soap

2. Handwashing with

soap before feeding

child (by mother) and

before eating (by child)

3. Proper storage of cooked

food in container with tight lid

4. Thorough re-heating

of leftover/stored food

(Maintain re-heating temp at

least at 700c)

Five key prioritized

food hygiene

behaviours

5. Water and milk

treatment (boil

milk and water)

Targeted five key food hygiene behaviours (in sequential order)

Food Hygiene Trial:

Multiple BC in Nepal

Prevalence of key food hygiene behaviours – intervention arm

(before – after)

1 3 5 5

24

3 1

43

55

67 67

88 86

77

0

10

20

30

40

50

60

70

80

90

100

All Cleanlinessof servingutensils

HWWS bymotherbeforefeeding

HWWS bychild before

eating

Properstorage

Thoroughre-heating &maintained

temp

Watertreatment

Fo

od

hyg

ien

e b

eh

avio

urs

wh

en

ob

serv

ed

(%

)

Before (n=120) After (119)

• program

development

process

Behaviour Setting

Assess & Build

Create

Deliver

Intervention Environment

BCD Program Process Model

Behaviour

Evaluate

State-of-

the-World

Performance Revaluation Surprise

[Outcomes] [Outputs] [Implementation] [Inputs] [Impact]

Brain

Body

A

Assess

A1

Inception

A2

Background/ evidence

review

A3

Framing Workshop

Formative Research

Plan

Inception meeting

• Engage/

Align

stakeholders

• Get

institutional

buy-in

Review the literature

Review what is known about the

target behaviour globally and in

your local context.

The compilation of this

information should paint a

picture of the current ‘state of the

world’.

The report should highlight what

is known and what is unknown.

Framing Workshop

B

Build

B1

Develop FR protocol

B2

Field research

B3

Analysis and

reporting

B4

Creative Workshop

Theory of change/

Creative Brief

Daily script

Body Image

Video ethnography

Creative Workshop

Insight development process

Touchpoints

Creative Brief (Kombonis) • STAKEHOLDERS

• Project stakeholders are; Centre for Infectious Disease Research in Zambia (CIDRZ), Zambian Ministry of Community

Development, Mother and Child Health (MCDMCH), Ministry of Health (MOH), Absolute Return for Kids (ARK). Research,

behaviour change, intervention design and evaluation guidance is from the London School of Hygiene & Tropical

Medicine (LSHTM).

• BACKGROUND

• What are the facts about diarrhoea and behaviour change?

• Every year, Zambia’s 2.4 million children under five years of age experience over 10 million episodes of diarrhoea; more

than 840,000 of these children visit a health facility at least once for diarrhoea, 63,000 will be hospitalised, and at least

15,000 will die.

• What do we know about these behaviours now?

• Infant feeding behaviour:

• Mothers are able to tell you that women should exclusively breastfeed until their baby is 6 months of age, but in reality most

EBF for the first month only and then gradually introduce foods (e.g., porridge) and liquids (e.g. Maheu) alongside breast

milk after that. In depth research reports on the three individual behaviours are available.

• TARGETS FOR BEHAVIOUR CHANGE

• We want to reduce diarrhoea among under-fives in peri-urban and rural low-income households in our Lusaka Province

pilot areas. This means changing behaviour among the following groups:

• INTERVENTION DESIGN PRINCIPLES:

• Must work for rural and peri-urban settings and be scalable for the rest of Zambia.

• All implementation must work for low/no-literacy communities.

• (MEASURABLE) BEHAVIOURAL TASKS

• EBF: Address ‘for the poor’ low status image of breastfeeding – e.g., aspirational role models inc. higher-status mothers,

clinic workers in community to EBF, etc.

• Piggy- back on existing early intervention- points in early month(s) before the first mouthfuls of non-breast milk are

introduced and include fathers and grandmothers – i.e., clinic after birth, 6 day visit, 6 week visit, etc.

• AGENCY DELIVERABLES & REQUIREMENTS:

• The core agency outputs will be:

• Signed off strategy underpinning intervention design – this will specifically help us understand how to manage doing work

on three behaviours in communities within the pilot program.

1. EBF 2. HWWS 3. ORS + Zinc

Households Mothers of babies under 6 months who still EBF

All old enough to feed selves from family pot and go to toilet unassisted

Household heads (men & grandmothers)

Mothers of children 1-59 months

Household heads (men & grandmothers)

Clinic staff & health workers

Health workers who promote EBF (?)

Health workers, clinicians, pharmacists

Private pharmacies Owners, dispensers

Shops, soap sellers Owners

C

Create

C1

Concept generation

C2

Prototype Testing

C3

Material production

Delivery Plan

Professional Creativity

body

behaviour

social

physical environment

bio- logical

settin

g

motivated

executive

reactive

brain

Types of intervention

Baduta Creative Process

• Over 4 month period:

• 16 reverts on TVCs

• 6 reverts on community events/materials

• ≅ 25 international Skype calls

ALTERNATIVE SOFTER BACKGROUNDS – ALT 01

NOTE: The Sketches will be real photograph

Cut to dan wide shot nampak ibu baduta keluar dari rumah membawa semangkuk buah-buahan (yang dipotong kecil-

kecil seperti dadu)dengan garpu sambil menghampiri bayinya

Ibu Baduta: “Ngemilnya yang sehat saja seperti buah-buahan ”

Cut to and camera wide shot, the baduta mother came out from her house with the bowl of fruit

Baduta Mom: “Only healthy snacking allowed like fruits”

Rumpi Sehat Weekly Program & Activities

• Baby Health Check-Up and Consultation

Pojok Rumpi

• Rumpi Chain Message

• Baby & Father Crawling

• Fill the Baby Plate

• Snapping the bottle

Fun Games

• Female singer and Keyboard Player (Electone singer)

• Nenen Dance Competition (Breastfeed Dance)

Entertainment

Duration : 9am – 13am

Target : 300 – 500 participants

Cut dan medium shot nenek si bayi langsung menepis tangan bu Gunjing

yang hendak memberi cucunya kerupuk

Nenek: “Jangan kasih cucuku cemilan sembarangan, abis gini waktunya makan,

nanti dia kenyang duluan”

Cut and medium shot. The grandmother snap away ibu gunjing’s hand.

Nenek: “No, don’t give my grandchild carelessly snack, it’s about meal time

and you’re spoiling his appetite”

Detail Activity

09.30 – 10.30 : Workshop

Leads by MC;

Keynote speaker by Doctor

Share all information on:

new born baby;

the benefits of breast feeding compare

to bottle feeding

How to transfer breast feeding to family

food and improve nutritional quality of

complimentary food

Q & A Session

Open for any questions from all

participants

Doctor ‘chat’

Baby/dad crawling race

Poster idea

Rumpi Sehat Monthly Program & Activities

Associated with Kampung Guyub – JTV

Electone with Singer

Nenen Dance

Entertainment

Aerobics

Giant Baby Feeding

Baby Crawling (Father’s Games)

Cooking Competition with Mystery Box

Fun Games

Baby Health Check and Consultation

Interactive Seminar

ASI Experience Zone

Pojok Rumpi

Cooking Demonstration

Live Demo

Duration : 7am – 13.30am

Target : 700 – 900 participants

Aerobics

Pre-test ideas

D

Deliver

D1

Roll-Out

D2

Monitor

D3

Adapt

Delivery Report

E

Evaluate

E1

Process Analysis

E2

Outcome Analysis

E3

Evaluation Report

Dissemination/

Learning Plan

Process vs Impact

Behaviour Setting

Intervention Environment Behaviour State-of-

the-World

[Outcomes] [Outputs] [Implementation] [Inputs] [Impact]

Brain

Body

Process Evaluation Impact Evaluation

Wall of All

Impact evaluation

2%4% 6%

29%

1%

19%

37%

29%

0%

5%

10%

15%

20%

25%

30%

35%

40%

baseline 1st follow up 2nd follow up 3rd follow up

han

dw

ash

ing

at t

arge

t ev

ents

intervention in first half of villages

intervention in control villages

19% 19%

19%

41%

21%

36%

51%

43%

0%

10%

20%

30%

40%

50%

60%

baseline 1st follow up 2nd follow up 3rd follow up

soap

use

for

han

dw

ash

ing

intervention in first half of villages

intervention in control villages

(6 weeks) (6 months) (12 months)

View Intervention Control

HWWS is good manners 84% 21%

HWWS protects children 63% 2%

HWWS leads to success

in life 30% 0%

Everybody around here

WHWS 35% 8%

Process Evaluation

Conclusions

• BCD is a generic framework

• BCD is based on strong theory

(reinforcement learning, evolutionary

and ecological psychology)

• BCD process is based in design thinking

and creative interventions

• BCD produces behaviour change

BCD Materials

1. WWW.EHG/BehaviourCentredDesign for manual and papers : Aunger and Curtis, Kinds of Behavior, Aunger and Curtis The Anatomy of Motivation

2. Ghana handwashing ad (1990s)

https://www.youtube.com/watch?v=w2qRcMTstzc 3. SuperAmma Indian handwashing campaign (2013) (including films) http://www.superamma.org 4. Zambian multiple behaviour change campaign (2014) EBF: https://youtu.be/KACFLZjkg1c ORS: https://www.youtube.com/watch?v=sHS6fmt4MRg Handwashing: https://www.youtube.com/watch?v=NoOic0KjYLw 5. Indonesian child nutrition program: EBF: https://www.youtube.com/watch?v=slG8oW4Xdzg Complementary foods: https://www.youtube.com/watch?v=opDsBbKMWCo Healthy snacking: https://www.youtube.com/watch?v=q2YmQzud3-8 Social media: https://www.facebook.com/GerakanRumpiSehat?fref=ts